Determinants of Length of Stay After Operative Treatment for Femur Fractures

Predictors of outcomes after internal fixation of periprosthetic femoral hip fractures Subgroup analysis of the peri-implant and peri-prosthetic fractures Spanish registry (PIPPAS)

PURPOSE

To identify risk factors predisposing patients to poor outcomes after fixation of periprosthetic hip fractures around femoral stems.

METHODS

Prospective multicentre cohort study of fractures around a hip replacement stem managed by internal fixation. The primary outcome was one-year mortality, while secondary outcomes were local complications and healthcare burden-related outcomes (nursing facility utilization and hospital length of stay).

RESULTS

One-year mortality was 16.2%. Age-adjusted Charlson Comorbidity Index score (OR=1.17; 95%CI=1.03-1.33)), Pfeiffer Short Portable Mental Status Questionnaire (SPMSQ) score (OR=1.16; 1.06-1.28), prosthetic dysfunction (OR=1.90; 1.00-3.61), and postoperative medical complications (OR=1.97; 1.06-3.68) were predictors of mortality. Patients with prior prosthetic dysfunction, lower Pfeiffer SPMSQ scores, Vancouver A fractures, and fractures fixed only using cerclages were at higher risk of local complications, which occurred in 9.3% of cases. Medical (OR=1.81; 1.05-3.13) and local complications (OR=5.56; 2.42-3.13) emerged as consistent risk factors for new institutionalization. Average hospitalization time was 13.9±9.2 days. Each day of fixation delay led to an average 1.4-day increase in total hospitalization.

CONCLUSION

Frail periprosthetic hip-fracture patients with poorer functional status, dysfunctional replacements, and postoperative complications are at increased risk of mortality. Postoperative complications are more common in patients with dysfunctional arthroplasties, Vancouver A fractures, and fixation using cerclages alone. Postoperative complications were the most consistent predictor of higher healthcare resource utilization.

A cost-effectiveness analysis of surgical care delivery in Eastern Uganda-a societal perspective

BACKGROUND

The mismatch between the global burden of surgical disease and global health funding for surgical illness exacerbates disparities in surgical care access worldwide. Amidst competing priorities, governments need to rationally allocate scarce resources to address local needs. To build an investment case for surgery, economic data on surgical care delivery is needed. This study focuses on femur fractures.

METHODS

This prospective cohort study at Soroti Regional Referral Hospital (SRRH), captured demographic, clinical, and cost data from all surgical inpatients and their caregivers at SRRH from February 2018 through July 2019. We performed descriptive and inferential analyses. We estimated the cost effectiveness of intramedullary nailing relative to traction for femur fractures by using primary data and making extrapolations using regional data.

RESULTS

Among the 546 patients, 111 (20.3%) had femur fractures and their median [IQR] length of hospitalization was 27 days [14, 36 days]. The total societal cost and Quality Adjusted Life Year (QALY) gained was USD 61,748.10 and 78.81 for femur traction and USD 23,809 and 85.47 for intramedullary nailing. Intramedullary nailing was dominant over traction of femur fractures with an Incremental Cost Effectiveness Ratio of USD 5,681.75 per QALY gained.

CONCLUSION

Femur fractures are the most prevalent and most expensive surgical condition at SRRH. Relative to intramedullary nailing, the use of femur traction at SRRH is not cost effective. There is a need to explore and adopt more cost-effective approaches like internal fixation.

Risk factors for complications within 30 days of operatively fixed periprosthetic femur fractures

BACKGROUND

With a rising number of periprosthetic femur fractures (PPFFs) each year, the primary objective of our study was to quantify risk factors that predict complications following operative treatment of PPFFs.

METHODS

A retrospective cohort study of 231 patients with a periprosthetic femur fracture was conducted at an Academic, Level 1 Trauma Center. The main outcome measurement of interest was complications, as defined by the ACS-NSQIP, within 30 days of surgery.

RESULTS

56 patients had 96 complications. Bivariate analyses revealed ASA score, preoperative ambulatory status, length of stay, discharge disposition, time from admission to surgery, length of surgery, perioperative change in hemoglobin, Charlson comorbidity index, cerebral vascular accident/transient ischemic attack, chronic obstructive pulmonary disease, diabetes mellitus, and receipt of a blood transfusion were associated with development of a complication (p < 0.1). Multivariate logistic regression showed length of stay (OR 1.11, 95% CI 1.03-1.19; p = 0.006), receipt of a blood transfusion (OR 2.48, 95% CI 1.14-5.42; p = 0.02), and diabetes mellitus (OR 2.17, 95% CI 1.03-4.56; p = 0.04) remained independently predictive of complication.

CONCLUSIONS

Length of stay, receipt of a blood transfusion, and diabetes were associated with increased perioperative risk for developing a complication following operative treatment of periprosthetic femur fractures. Methods to decrease length of stay or transfusion rates may mitigate complication risk in these patients.

LEVEL OF EVIDENCE

Prognostic, Level III.

Is Frailty Associated with Adverse Outcomes After Orthopaedic Surgery?: A Systematic Review and Assessment of Definitions

BACKGROUND

There is increasing evidence supporting the association between frailty and adverse outcomes after surgery. There is, however, no consensus on how frailty should be assessed and used to inform treatment. In this review, we aimed to synthesize the current literature on the use of frailty as a predictor of adverse outcomes following orthopaedic surgery by (1) identifying the frailty instruments used and (2) evaluating the strength of the association between frailty and adverse outcomes after orthopaedic surgery.

METHODS

A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched to identify articles that reported on outcomes after orthopaedic surgery within frail populations. Only studies that defined frail patients using a frailty instrument were included. The methodological quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). Study demographic information, frailty instrument information (e.g., number of items, domains included), and clinical outcome measures (including mortality, readmissions, and length of stay) were collected and reported.

RESULTS

The initial search yielded 630 articles. Of these, 177 articles underwent full-text review; 82 articles were ultimately included and analyzed. The modified frailty index (mFI) was the most commonly used frailty instrument (38% of the studies used the mFI-11 [11-item mFI], and 24% of the studies used the mFI-5 [5-item mFI]), although a large variety of instruments were used (24 different instruments identified). Total joint arthroplasty (22%), hip fracture management (17%), and adult spinal deformity management (15%) were the most frequently studied procedures. Complications (71%) and mortality (51%) were the most frequently reported outcomes; 17% of studies reported on a functional outcome.

CONCLUSIONS

There is no consensus on the best approach to defining frailty among orthopaedic surgery patients, although instruments based on the accumulation-of-deficits model (such as the mFI) were the most common. Frailty was highly associated with adverse outcomes, but the majority of the studies were retrospective and did not identify frailty prospectively in a prediction model. Although many outcomes were described (complications and mortality being the most common), there was a considerable amount of heterogeneity in measurement strategy and subsequent strength of association. Future investigations evaluating the association between frailty and orthopaedic surgical outcomes should focus on prospective study designs, long-term outcomes, and assessments of patient-reported outcomes and/or functional recovery scores.

CLINICAL RELEVANCE

Preoperatively identifying high-risk orthopaedic surgery patients through frailty instruments has the potential to improve patient outcomes. Frailty screenings can create opportunities for targeted intervention efforts and guide patient-provider decision-making.

The societal cost and economic impact of surgical care on patients' households in rural Uganda; a mixed method study

Background

The epidemiology and cost of surgical care delivery in low-and middle-income countries (LMICs) is poorly understood. This study characterizes the cost of surgical care, rate of catastrophic medical expenditure and medical impoverishment, and impact of surgical hospitalization on patients’ households at Soroti Regional Referral Hospital (SRRH), Uganda.

Methods

We prospectively collected demographic, clinical, and cost data from all surgical inpatients and caregivers at SRRH between February 2018 and January 2019. We conducted and thematically analyzed qualitative interviews to discern the impact of hospitalization on patients’ households. We employed the chi-square, t-test, ANOVA, and Bonferroni tests and built regression models to identify predictors of societal cost of surgical care. Out of pocket spending (OOPS) and catastrophic expenses were determined.

Results

We encountered 546 patients, mostly male (62%) peasant farmers (42%), at a median age of 22 years; and 615 caregivers, typically married (87%), female (69%), at a median age of 35 years. Femur fractures (20.4%), soft tissue infections (12.3%), and non-femur fractures (11.9%) were commonest. The total societal cost of surgical care was USD 147,378 with femur fractures (USD 47,879), intestinal obstruction (USD 18,737) and non-femur fractures (USD 10,212) as the leading contributors. Procedures (40%) and supplies (12%) were the largest components of societal cost. About 29% of patients suffered catastrophic expenses and 31% were medically impoverished.

Conclusion

Despite free care, surgical conditions cause catastrophic expenses and impoverishment in Uganda. Femur fracture is the most expensive surgical condition due to prolonged hospitalization associated with traction immobilization and lack of treatment modalities with shorter hospitalization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06579-x.

Pressure injuries, obesity and mental health concerns on admission to rehabilitation are associated with increased orthopaedic rehabilitation length of stay

OBJECTIVE

To investigate the association between a set of comprehensive factors across international literature and rehabilitation length of stay.

METHOD

A chart audit of 197 Australian hospital rehabilitation unit orthopaedic inpatients (2016-2018) was conducted. Items significantly associated with length of stay throughout univariate regressions were entered into a subsequent hierarchical multiple regression analysis, where variables were regressed against length of stay in two steps. Items which were relevant prior to admission to the rehabilitation unit, or immediately upon admission, were regressed against length of stay during the first step, while variables which emerged during admission were entered during the second step.

RESULTS

Having pressure injuries during rehabilitation (p < .001), limited compliance in rehabilitation programs (p = .007), mental health concerns on admission to rehabilitation (p = .007), being obese (p < .001), and having significant pain impacting function (p = .03) were all independently significantly associated with an increased length of stay. Higher Functional Independence Measure motor (p < .001) subscale scores on admission to rehabilitation were associated with decreased length of stay. A hierarchical multiple regression analysis found that pressure injuries during rehabilitation (p = .002), being obese (p = .04), having mental health concerns on admission to rehabilitation (p = .03), and Functional Independence Measure subscale scores on admission (p = .04) were significantly associated with length of stay.

CONCLUSION

It is imperative that clinical programs and interventions promoting mental health outcomes, and addressing the distinct needs of obese inpatients, are delivered in the rehabilitation context.

Preoperative Evaluation of the Frail Patient

Perioperative management of older adults is a complex field that is heavily influenced by the clinical heterogeneity of older adults. Frailty-a geriatric syndrome in which a patient is more vulnerable to stressors due to decreases in physical function and reserve-has been indicative of adverse postoperative outcomes. Many tools have been developed to measure frailty that incorporate a variety of factors including physical and cognitive function, comorbidities, self-reported measures of health, and clinical judgment. Most of these frailty assessment tools are able to identify a subset of patients at risk of adverse outcomes including postoperative complications, longer hospital length of stay, discharge to a higher level of care, and mortality. Frailty assessment before surgical interventions can also guide discussions among patients, their families, anesthesiologists, and surgeons to tailor operative plans for patients to mitigate this increased risk. Studies are ongoing to identify interventions in frail patients that can improve postoperative outcomes, but high-quality data in the form of randomized controlled trials are lacking at this time.

Modifiable, Postoperative Risk Factors for Delayed Discharge Following Total Knee Arthroplasty: The Influence of Hypotension and Opioid Use

BACKGROUND

We sought to identify independent modifiable risk factors for delayed discharge after total knee arthroplasty (TKA) that have been previously underrepresented in the literature, particularly postoperative opioid use, postoperative laboratory abnormalities, and the frequency of hypotensive events.

METHODS

Data from 1033 patients undergoing TKA for primary osteoarthritis of the knee between June 2012 and August 2014 at an academic orthopedic specialty hospital were reviewed. Patient demographics, comorbidities, inpatient opioid medication, postoperative hypotensive events, and abnormalities in laboratory values, all occurring on postoperative day 0 or 1, were collected. Multivariate logistic regression analysis was performed to identify independent risk factors for a prolonged length of stay (LOS) >3 days.

RESULTS

The average age of patients undergoing primary TKA in our cohort was 65.9 (standard deviation, 9.1) years, and 61.7% were women. The mean LOS for all patients was 2.64 days (standard deviation, 1.14; range, 1-9). And 15.3% of patients had a LOS >3 days. On multivariate logistic regression analysis, nonmodifiable risk factors associated with a prolonged LOS included nonwhite race (odds ratio [OR], 2.01), single marital status (OR, 1.53), and increasing age (OR, 1.47). Modifiable risk factors included every 5 postoperative hypotensive events (OR, 1.31), 10-mg increases in oral morphine equivalent consumption (OR, 1.04), and postoperative laboratory abnormalities (hypocalcemia: OR, 2.15; low hemoglobin: OR, 2.63).

CONCLUSION

This study identifies potentially modifiable factors that are associated with increased LOS after TKA. Doubling down on efforts to control the narcotic use and to use opioid alternatives when possible will likely have efficacy in reducing LOS. Attempts should be made to correct laboratory abnormalities and to be cognizant of patient opioid use, age, and race when considering potential avenues to reduce LOS.